B.C.'s fentanyl crisis: The view from the front lines

Long before the overdose crisis was declared a public health emergency in April, first responders, doctors and the loved ones of drug users could see plenty of hard work and heartache ahead.

Last month, the B.C. Coroners Service announced that 555 people had died from an illicit-drug overdose in B.C. in the first nine months of 2016, compared to 505 for all of 2015. Coroners statistics show that fentanyl — a powerful synthetic opioid dealers are cutting into drugs of all kinds — was detected in about 61 per cent of these overdoses.

As the fentanyl crisis continues to devastate communities across B.C., people who live and work through it every day share stories from the front lines.

Al Pruden: “It’s hard for us because we know that there’s other calls that we could be going on, other people that need us for other reasons, other medical conditions, other accidents and things like that.”Rafe Arnott /
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Al Pruden, the paramedic

It’s been an exceptionally busy year for B.C.’s 4,100 paramedics.

In 2015, crews responded to 12,260 suspected overdose and poisoning events but in the first nine months of 2016 had already handled 12,911.

Pruden, a primary-care paramedic with the B.C. Ambulance Service, described one “very chaotic scene” in August where he responded to multiple people overdosing simultaneously in an alleyway, including someone in cardiac arrest.

“To roll up on that scene and see not one ambulance or one fire truck, but multiple ambulances, multiple fire crews, police officers and the public all working together for these individuals that are in the throes of an overdose … Thankfully, everybody survived because we were there and everything was done to the letter,” he said.

Teams used to respond to one or two overdose calls per four-day work block, Pruden said. Lately, it’s four or five such calls every day. In 2015, paramedics administered the overdose-reducing drug naloxone at 3,096 events; in the first nine months of 2016, they’d already administered it at 3,372, according to B.C. Emergency Health Services.

“With the increase in overdoses … yeah, it does wear on our crews,” said Pruden, who works out of Vancouver. “It’s hard for us because we know that there’s other calls that we could be going on, other people that need us for other reasons, other medical conditions, other accidents and things like that.”

Because overdoses are “life or death” emergencies, paramedics must make them a priority, Pruden said, adding that they are often called to treat the same overdose victim multiple times.

Sometimes their first thought is, “Oh no, not again,” Pruden said, but they remind themselves that saving lives is the reason they took the job.

“It’s unfortunate that in some neighbourhoods we do see the same people, the same clients, multiple times in the course of our careers, if not in the course of a week,” he said. “You feel bad. They’re still patients and they’re people. Unfortunately, they’re in the situation they’re in, and each time we’re there to help them.”

Pruden believes there’s still a misconception that only entrenched heroin users are overdosing on fentanyl. But paramedics have rushed to suburban house parties after groups have overdosed together on tainted cocaine, he said.

“It’s not just a Lower Mainland problem,” he said. “It’s Kelowna, it’s Kamloops, it’s Prince George, it’s Prince Rupert. There are no boundaries to where this fentanyl is showing up in drugs and the crisis it’s created.”

Samona Marsh: “How many more friends do I have to lose before something’s really done?”Rafe Arnott /
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Samona Marsh, the peer

“I hate the sound of sirens,” said Samona Marsh while striding down Hastings Street near Gore Avenue, with a reporter and photographer struggling to keep up.

Marsh, a crystal meth user, is a board member of the Vancouver Area Network of Drug Users.

Lately, she’s been hearing sirens often in this area, not far from where a fentanyl overdose killed her friend Trevor on Aug. 31. He was 27 when he smoked what he thought was heroin, overdosed and died in broad daylight at the northwest corner of Main and Hastings.

Despite Aug. 31 being International Overdose Awareness Day, no one in the area was carrying naloxone when Trevor died, Marsh said.

“It should be like your American Express card — don’t leave home without it,” she said.

Marsh is angry that fentanyl is being cut into drugs of all kinds. People are overdosing in alleyways and near the Insite supervised-injection site, she said. A recent study found fentanyl was turning up in 86 per cent of drugs that users brought to Insite.

Despite bolstered harm-reduction measures, locals wake up daily to tragic news. Marsh learned of Trevor’s death through chatter on the street. Art in alleyways, sidewalk memorials and photos posted in the neighbourhood also keep her apprised of fentanyl’s latest victims.

“Of course it upsets us, but in the Downtown Eastside, death is like — it’s like getting up and washing your face, you know?” Marsh said. “Every day you hear of someone else OD’ing or getting stabbed or some crazy stuff.”

Still, Marsh has shed plenty of tears over Trevor and others who have died from an overdose.

“It’s almost like, ‘Who’s next?’” she said. “How many more friends do I have to lose before something’s really done?”

She has a few suggestions: build more Insites; increase access to prescription heroin; warn all drug users to “taste it, try it and be with a friend.”

In the meantime, Marsh will focus on spreading kindness in the community and checking in with her drug-using acquaintances frequently — something she does several times while being interviewed.

While walking to a VANDU meeting, Marsh paused to comfort a woman who was sobbing and all alone outside the Savoy Pub.

“Her friend just died of an overdose,” Marsh said. “Two days ago. The same day as my friend Ron.”

Seonaid Nolan, the doctor

The emergency department at St. Paul’s Hospital in Vancouver has seen an “astronomical” number of patients who have overdosed, said Dr. Seonaid Nolan, an addictions physician with the B.C. Centre for Excellence in HIV/AIDS.

“I think it’s really affecting everyone, and not just the people who are using themselves but … frontline workers, families of individuals who use drugs, friends, loved ones,” said Nolan, who has gone on maternity leave since the original reporting for this article. “It’s having an impact on everyone.”

Between Jan. 1 and Oct. 1, Vancouver Coastal Health emergency departments handled 4,628 illicit or unknown drug overdoses, with 70 per cent of them at St. Paul’s.

An increasing number of patients who have overdosed are being referred to Nolan and the addictions team at St. Paul’s. Three years ago, the team would see three or four new referrals every morning, but the fentanyl crisis has changed that dramatically.

“Six is probably the minimum average and we’ve gone up to between 15-20,” Nolan said.

“We’re following 90 patients sometimes and, despite that, looking at the statistics coming through St. Paul’s, I think the addiction-consult service is still only seeing about 20 per cent of patients who present or are admitted for a substance-use disorder.”

Three addiction-medicine physicians and their teams of residents are working to keep up with inpatient referrals. St. Paul’s recently added a 4th physician dedicated to seeing patients in the ER, whose role is to engage opioid-use disordered patients and to staff a new outpatient, rapid-access addiction clinic.

Confronted by the fentanyl crisis, Nolan’s team changed how it manages overdoses. They more routinely test patients for fentanyl and now offer take-home naloxone kits to both illicit-drug users and patients receiving high doses of prescription opioids.

They’re also working to get more patients on Suboxone, the preferred treatment for opioid addiction.

And every chance they get, Nolan and her colleagues use an emergency department visit to “capitalize on a moment” when doctors can help patients find motivation and resources to treat their addiction, she said.

But Nolan said she is frustrated by the “broken” system and the waitlists for addiction-treatment facilities that patients face when they are released from her care.

“Knowing that the system that exists to help support them when they leave the hospital doors is not optimal is, I think, where our efforts need to be focused next,” she said.

Meanwhile, she finds solace in her work.

“It’s hectic, it’s chaotic, it’s very busy,” she said. “But it’s also very rewarding and I feel like now is a critical time where you feel like you can actually have an impact in someone’s life – which is why I went into medicine in the first place.”

Lisa Lapointe: “Right now, we’re looking at eight to nine months — to a year — to get (our public reports) done. That’s really wearing on the coroners and it’s very challenging for the families.”Rafe Arnott /
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Lisa Lapointe, the coroner

Until this year, suicide was the leading cause of unnatural death in B.C., killing about 600 people each year. But that has been surpassed by illicit-drug overdose. If the crisis continues at its current rate, 740 people will die of an overdose by the end of 2016.

Lisa Lapointe, B.C.’s chief coroner, believes that if it weren’t for the distribution of 15,000 take-home naloxone kits and increased access to Suboxone, the death toll would easily be in the thousands.

But the impact of fentanyl has meant a backlog of coroner’s reports that has left families agonizing over what, exactly, happened to their loved ones.

“Ideally, we would like to have all of our public reports completed in 4½ months,” Lapointe said. “But right now, we’re looking at eight to nine months — to a year — to get those done. That’s really wearing on the coroners and it’s very challenging for the families.”

B.C.’s 95 coroners, who investigate roughly 8,500 deaths in the province every year, might spend two to three hours at the scene of a death. They collect data on the individual’s age, sex and location of death — all vital details for the agencies forming a response to the crisis.

Increasingly, coroners are investigating whether the deceased had suffered a previous overdose, had been through a period of abstinence or had struggled with mental illness, Lapointe said.

They contact the deceased’s physician, collect hospital records and gather PharmaNet records to find out whether the deceased was “doctor shopping” or using prescription drugs along with illicit drugs. A new Drug Death Investigation Team, announced Tuesday, will have 12 coroners working to bolster this information collection.

Perhaps most importantly, the coroners work closely with the deceased’s family, recognizing that the deceased may have been a loved one who died because of their struggle with drug addiction.

“Every scene a coroner goes to is a scene of death, so coroners need to be and are very compassionate in terms of dealing with families,” Lapointe said. “This is very often the worst time of a person’s life, the sudden death of a loved one — something unexpected.”

Throughout the investigation, they regularly phone family members with new information.

“They are feeling the pressure of the workload, they really are,” she said. “They’re feeling badly that they’re not getting back to families as quickly as they’d like to.”

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